It's official. U.S. HIV treatment guidelines, updated in December, now recommend starting therapy when a person's T-cells drop to 350.

The previous recommendation was 200. However, therapy is recommended for anyone, regardless of T-cell count, who has had an AIDS-defining illness (such as PCP), is pregnant, has HIV-associated nephropathy (kidney illness), or have hepatitis B for which treatment is warranted. Treatment should be considered for people with T-cells between 350 and 500, although the panel of experts was divided on the strength of this recommendation. The panel was more divided on the idea of starting therapy above 500 T-cells: half was for it, half saw it as optional.

Always of interest in guideline changes are recommendations for drug treatment. The following recommendations were made for people taking HIV treatment for the first time:

• Isentress + Truvada was added as a preferred regimen.
  
• Kaletra was downgraded from the preferred list to "alternative," except for pregnant women.
  
• Lexiva/Norvir twice daily was also dropped from preferred to alternative.
  For when to use genotypic versus phenotypic resistance testing in treatment-experienced patients with viremia while on therapy, the guidelines recommend:
  
• Genotypic testing in patients with suboptimal virologic responses or viologic failures while on their first or second regimen; and
  
• The addition of phenotypic testing to genotypic testing is generally preferred for persons with known or suspected complex drug resistance mutation patterns, particularly to protease inhibitors.
  Substantial changes were made to these areas:
  
• What not to use;
  
• Management of treatment-experienced patients;
  
• Treatment simplification;
  
• Hepatitis C co-infection;
  
• Antiretroviral-associated adverse effects;
  
• Antiretroviral drug interactions; and
  
• Preventing secondary transmission of HIV.
  

The guidelines panel also added a section on treatment consideration for HIV-2, the virus endemic in poor countries. Visit the NIH online to see the guidelines.